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MediPace of Beverly Hills, Inc

MediPace of Beverly Hills, Inc 2025

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The document outlines the office policies and consent forms for MediPace of Beverly Hills, Inc., specifically regarding patient consent for treatment, financial responsibilities, no-show fees, electronic communication authorization, and the process for obtaining medical records. It also includes conditions under which a patient may be discharged from the practice.

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Click ‘Get Form’ to open the MediPace of Beverly Hills, Inc document in the editor.
Begin by filling out your personal information at the top of the form. Ensure that all details are accurate to avoid any issues with your medical care.
In the Consent section, read through the authorization statement carefully. If you agree, sign and date where indicated. If you are a minor, ensure a legal guardian signs on your behalf.
Review the Financial Responsibility clause. Fill in your credit card information for any potential charges and initial as required to confirm your understanding.
For Electronic Communication, indicate your preference by checking the appropriate box. If you do not consent, make sure to notify staff in writing.
Finally, sign and date at the bottom of the form. Ensure that a witness is present if required.

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